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MARRCH 2014 Annual Conference Sharpening Our Core Functions: Skills-Based Learning

MARRCH Ethics Committee Advanced Ethics: Part II

Doug Greenlee MA/MS, LMFT, LADC, CGC Staff Psychotherapist

Recovery Plus – St. Cloud Hospital And MARRCH ETHICS Committee members

MARRCH Advance Submission Information: Power Point & Presentation Adjustments

At MARRCH’s workshop request, I have submitted this power point and related information for your perusal by or before 9/19/14. However, prior to the actual presentation on 10/29/14, I will review the power point and related materials, making adjustments/edits as needed.

As you may have noticed, some of the slides are rather ‘busy.’ Please keep in mind that I am using the ppt. in two ways: 1) As a guide for presentation materials; 2) As an information resource tool--i. e., various slides contain direct quotations and source identification if you would like to review the related information.

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MARRCH Advance Submission Information: Power Point & Presentation Adjustments

Along with the ppt., I have submitted a variety of resources which include a working bibliography reference, White Cultural Awareness/Privilege exercise, Feminist and Multicultural ethics information, etc. Given the time restrictions, I will only reference this material, as needed. Feel free to review and use it at your discretion.

For the presentation only, I will have some paper handouts for the two basic ethics problem solving scenarios. These examples are meant to be brief opportunities for exploring common CD/MH client circumstances via the MARRCH ethical problem analysis format nuanced with cultural power dynamics taken from Frames’ Multicultural Ethics Problem Solving model.

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Overview Snapshot

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Clinical Practice

Culture & Privilege Awareness

Change

Clinical Practice

• Ethics

• Competence

• Systemic

• Personal

• Personal

• Paradigm

• Self & Client

• TX & Ethical Implications & problems

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Awareness, Clinical Competence & Change

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Setting the Context: Mindful Awareness Activity

1) Mindful Breathing for 60 seconds (Grounding Activity) 2) When you have finished your breathing awareness exercise, please notice your neighbor to your right, your left, and scan the audience.

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Mindfulness - Notice? 2) When you have finished your breathing awareness exercise, please notice your neighbor to your right, your left, and scan the audience. ________________________________________ 3) With whom are you similar? Dissimilar? Why? Which race, ethnic group, sex/gender is dominant within the group? Non-dominant? 4)Is what you noticed about yourself and others a source of comfort or discomfort? Why?

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Starting the Discussion: Awareness & Reflection

• What is it like for you to be a white male or

female in the US culture as you know it?

• What is it like for you to be a white non-white male/female in the US culture as you know it?

• How do you understand/experience power in

your daily life?

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Professional Competence as Personal Value & Ethical

Mandate

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Competence?

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Ethical Practice Demand: Competency

Board of Behavioral Health and Therapy Surd. 9.Competence.

"Competence" means the ability to provide services within the practice of alcohol and drug counseling as defined in subdivision 18, that:

(1) are rendered with reasonable skill and safety;

(2) meet minimum standards of acceptable and prevailing practice as described in section 148F.12; and

(3) take into account human diversity.

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Competence Goal: > Effective Alliance = > TX Effectiveness

Competence

Therapeutic Alliance

Counselor’s self-awareness of

gender & inter/intra

cultural dynamics

Counselor’s awareness of

client’s gender & inter/intra

cultural dynamics

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Competence Challenges & Opportunities

• Impacts:

• What?

• Whom?

• Impacts:

• Whom?

• How?

• Impacts:

• Whom?

• How?

• Impacts:

• Whom?

• What?

Systemic Changes

Personal Discrepancy

Ethical Challenges &

Opportunities Competence

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Background Guidelines: Pertinent Agency Oversight,

Legal, Demographics & Health In/Equity Information

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Organizational Clinical Competence Mandate: DHS Executive Summary: Policy and Overview Policy.

(2004)

The Minnesota Department of Human Services (DHS) encourages

health and human services providers and organizations to

demonstrate their ability to serve diverse populations before

they serve individuals from diverse cultures.

When an organization lacks knowledge and skills in a client’s

culture, it refers the client to someone who has the expertise.

The organization and its personnel are always accountable for

culturally appropriate services.

An organization cannot be clinically or programmatically

competent unless it is culturally competent. Health and human

services organizations can enhance their cultural competence with:

culturally competent personnel; culturally appropriate services;

culturally competent organizations

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Board of Behavioral Health and Therapy Specific Course Work Requirements

(i) an overview of the transdisciplinary foundations of alcohol and drug counseling, including theories of chemical dependency, the continuum of care, and the process of change;

(ii) (ii) pharmacology of substance abuse disorders and the dynamics of addiction, including medication-assisted therapy; (iii) professional and ethical responsibilities; (iv) multicultural aspects of chemical dependency; (v) co-occurring disorders; and (vi) the core functions defined in Minn. Stat. § 148F.01, subdivision 10

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2013 Minnesota Statutes:148F.51. Subd. 10.Core functions

• (1) "screening“

• (2) "intake“

• (3) "orientation“

• (4) "assessment“

• (5) "treatment planning“

• (6) "counseling"

• (7) "case management“

• (8) "crisis intervention“

• (9) "client education“

• (10) "referral“

• (11) "reports and record keeping“

• (12) "consultation”

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Practitioner Population: LADC Race/Ethnic Identification

68/70% male & 27/30% female > 85% Caucasian/7.5% non-white 2.6% Black 2.4% American Indian 1.4% Latino 0.6% Asian 0.5% identified as a combination of

Indian and non-Indian background.

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Between July 15, 2008 and October 26, 2008 MARRCH

surveyed all 1,765 Licensed Alcohol and Drug Counselors

(LADC) and Temporary Permit Holders (TPH) in Minnesota.

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MN Cultural Demographics

• MN Population, 2013 estimate 5,420,380

• White 86.2%

• Black or African American 5.7%

• American Indian and Alaska Native 1.3%

• Asian 4.5%

• Native Hawaiian and Other Pacific Islander 0.1%

• Two or More Races 2.3%

• Hispanic or Latino 5.0%

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Advancing Health Equity In MN (2014) MDH Report

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This report reveals that:

Even where health outcomes have improved overall, as in

infant mortality rates, the disparities in these outcomes

remain unchanged: American Indian and African American

babies are still dying at twice the rate of white babies.

Inequities in social and economic factors are the key

contributors to health disparities and ultimately are what

need to change if health equity is to be advanced.

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Advancing Health Equity In MN (2014) MDH Report

• Structural racism — the normalization of historical,

cultural, institutional and interpersonal dynamics that

routinely advantage white people while producing

cumulative and chronic adverse outcomes for people of

color and American Indians — is rarely talked about.

Revealing where structural racism is operating and where its

effects are being felt is essential for figuring out where

policies and programs can make the greatest improvements.

• Improving the health of those experiencing the greatest

inequities will result in improved health for all.

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Service Implications?

As demographics of the state are rapidly becoming more diverse:

Disparities in health and service outcomes exist between mainstream and diverse populations.

Access barriers mean clients’ needs are not identified and effective service is not provided.

Culture influences assessment accuracy and service effectiveness varies so quality may suffer.

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Service Implications?

• Law and accreditation standards increasingly

demand cultural competence.

Liability exposure increases and costs rise when

services are not effective.

Competition in funding and business markets favor the culturally competent organization

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Challenging White Cultural Awareness, Privilege and

Power

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So What Else is Changing?

White Cultural Privilege & Power Status Challenges

Political Awareness

Educational Paradigm

shifts

Professional oversight

Professional & Client

population shifts

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White Privilege & Racism: “A Crack in the wall”

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Paradigm Shifts: Feminism and Multiculturalism

• Social Justice challenges to dominant white and white-male majority-focused counseling model via awareness of:

• Power

• Patriarchy

• Privilege

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Paradigm Shifts: Feminism & TX Implications

Youtube: Carol Gilligan 28 10/9/2014

Women: 3rd Wave Feminism, Therapy Model and Cultural Reality

3rd Wave Feminism Stance

• Incorporates acute analysis of power in therapeutic relationship and practices, e.g. assessment, dx, and goals selection

• Sociostructural, cultural, relational dimensions part of conceptualization and practice

• Aforementioned linkages greatest strength and contribution of feminist therapy

‘Critical Psychology’ Movement

• Examines psychological theory from outside the dominant or mainstream view

• Gender is inseparable from race, ethnicity, social class and geographical region

• Justice/Healing? Must include three pillars: Gender sensitivity, cultural competence and ability to challenge status quo

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Mainstream Therapy Model

Feminist Model’s Components

• Assess sociostructural environment

• Client: identity in cultural context; political and relational setting of therapy; biologic and intrapsychic contributors

• Client-therapist negotiated agenda for therapy

• Spectrum of interventions from symptoms alleviation to working for justice

• Positive change for client individually leading to or including sociocultural change.

• Symptoms

• Treatment, preferably empirically validated

• Recovery as defined by the DSM

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Paradigm Shifts: Multicultural Model & TX Implications

Youtube: D. Sue 31 10/9/2014

Multicultural Counseling Model: The Fourth Force in Counseling

What is/How Does MCT Broaden Counselor Awareness?

• Helping Role and Process: MCT broadens counseling role awareness and related repertoire of therapy skills

• Interventions consistent with life experiences and cultural values: Effective use of modalities and goals that are consistent with clients racial, cultural, ethnic, gender, and sexual orientation backgrounds.

• Awareness of ind, group and universal dimensions of existence: Client’s identity understood from micro to macro social context awareness

• Universal and culture-specific strategies: Different racial/ethnic minority groups might respond best to culture-specific helping strategies

• Individualism and collectivism: Opportunity to balance individualist approach with an awareness of client’s embeddedness in families, Sig Other, communities and cultures.

• Client and client systems: Individual insight and problem-solving + social action/systemic change involvement to address/reduce racism, etc.

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Multicultural Counseling Competencies Applicable to Feminism and MCT models

Cultural Competence/ies

• Awareness: Aware of and sensitive to own culture while valuing and respecting differences, values difference and impact upon clients, and comfortable with self/others’ differences

• Cultural Competence: Knowledge - Informed about various culturally diverse groups, e.g. groups cslr works with, awareness of sociopolitical cultural and institutional barriers dynamics

• Cultural Competence: Skills – non/verbal skills, accurate communication, institutional interventions on behalf of client, active systemic interventions/not restricted by traditional counseling methods, e.g. working outside the office, changing environmental conditions rather than client, oriented toward prevention.

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Acculturation Model as Guide for Ethics-Based Personal &

Professional Identity Change Dynamics

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Developing/Changing a Professional Ethical Identity: Competence & Acculturation

Maintenance

Our personal moral sense that we bring to the ‘new’ clinical ethics culture, e.g., reviewing your motivations, values, and virtues expressions.

Contact and Participation

How much we identify with and adopt the traditions, values, and behaviors of the ‘new’ culture

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Developing/Changing a Professional Ethical Identity: Acculturation

Integration

Maintain personal moral sense and adopt professional ethics values

Assimilation

Abandon personal moral sense & accept fully professional ethics values

Separation

Maintain our personal moral sense and disregard professional ethics values

Marginalization

Obey professional ethics for convenience rather than moral commitment

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Ethics Models

• Virtue Ethics: Internal disposition/character-based, e.g. “Am I doing what is best for my client?”

• Aspirational Ethics: High standards of professional conduct vs. Mandatory ethics, e.g., meeting minimum requirements

• Care Ethics: Fostering and sustaining caring-based relationships & avoiding embarrassment, neglect and harm to the greatest number of people/clients

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Feminist and Multicultural Ethics Problem Scenarios

A paper handout will be available for audience members

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Ethical Problem Scenario: Problem Solve with a Feminist Perspective as Guide

Carol and her significant other drink together. Carol also has a child with her S/O and another child from a previous relationship. Carol’s current S/O has beaten her up several times in the recent past. Regardless, Carol refuses to report him to the police or social services because ‘he is the only one available to care for my children while I am working. I can’t afford daycare and I’ll lose my job, if I leave him. And he knows it!” Unfortunately, Carol and S/O were drinking recently in which S/O beat her up so badly, she had to go to the hospital for medical treatment. Carol still refused to press charges because “I have to think of my children.” However, Carol has decided to ‘clean-up’ so she meets with a ‘new/young’ white male CD counselor for assessment. The counselor recognizes that what has happened to Carol is ‘wrong and bad but she wasn’t willing to leave him! Doesn’t she kinda deserve what she got because she should have left him…Now, what am I supposed to do with all of her problems—in addition to her drinking issue?”

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Feminist Therapist Ethics: VERY limited overview of FTE

• Cultural Diversities and Oppressions: Assists client’s in accessing other services and intervenes when a client’s rights are violated.

• Power differentials: Clarifies power in its various forms as it exists within other areas of client’s life…assists clients in finding ways to protects themselves and seek redress.

• Overlapping Relationships: Recognizes the complexities and conflicting priorities…accepts responsibility for monitoring relationships to prevent potential abuse of or harm to the client.

• Therapist Accountability: Utilizes ongoing self-evaluation, peer support, consultation, supervision…acknowledges training limits…seeks to improve her competencies.

• Social Change: Seeks multiple avenues for impacting change…assists clients in intervening on their own behalf…encourages client’s recognition of criminal behaviors and facilitates client’s navigation of criminal system.

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MARRCH’s Integrative Decision-Making Models of Ethical Behavior in Counseling

Stage I: Interpreting the situation thru awareness and fact-finding

• Enhance sensitivity and awareness; Determine if dilemma or issue is involved; Determine major stakeholders/ethical claims in situation; Engage in fact-finding process

Stage II: Formulating an ethical decision

• Review problem/dilemma; Determine what ethical codes, laws, ethical principles, and institutional policies and procedures exist that apply to problem/dilemma; Generate possible and probable courses of action; Consider potential positive and negative consequences for each course of action; Consult with supervisors and other knowledgeable professionals; Select the best ethical course of action.

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MARRCH’s Integrative Decision-Making Models of Ethical Behavior in Counseling

Stage III: Selecting an action of weighing competing, non-moral values

• Engage in reflective recognition and analysis of personal competing values; Consider contextual influences on values selection at the collegial team, institutional, and societal levels

Stage IV: Planning and executing the selected course of action

• Figure out a reasonable sequence of actions to be taken; Anticipate and work out personal and contextual barriers to effective execution of the action plan, and effective counter measures for them; Carry out, document, and evaluate the course of action as planned

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Ethical Problem Scenario: Multicultural

At clinic ‘Serenity,’ approximately two thirds of the counseling staff are older, white males who have personally gone through treatment earlier and who have over time been grandfathered into the licensing process. It is unknown how many of these counselors have recently attended college courses or workshops/trainings to update their personal counseling education in light of changing requirements. What appears to be common among most of the male counselors is their strongly held belief that following the 12 Steps strictly will ‘keep you sober.’ Lately, non-white clients have been referred to the Serenity clinic for assessment and treatment. John, one of the older white male staff, has recently met with a Native American female who is in a broken relationship and responsible for several children. for assessment and treatment recommendations. Internally, John knows that he has very little understanding about her cultural interactions with her addictions and relapse history. John says to her, “The 12 Steps can help anyone get sober!” She seems willing to listen to his advice but states, “I can’t take the prejudice and racism I get from White culture anymore. It makes me want to keep drinking.” John replies, “I don’t see color or race: I treat everyone the same that I work with here.”

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Applying Multicultural Competencies to ethical scenario: VERY limited overview

Awareness of own cultural values: Awareness of own cultural heritage and identity and how it affects understanding of ab/normal…recognize limits of own multicultural competencies and expertise; aware of own racist, sexist, heterosexist or other detrimental attitudes and beliefs as it impacts clients/others

Understanding clients worldview: Awareness of stereotypes and neg/pos emotional reactions to other races/ethnic groups…possess specific knowledge about client group with whom working, understand how race/culture affects personality and how sociopolitical forces impinging upon lives of racial/ethnic minorities

Developing culturally appropriate interventions: Respects clients religious and spirituality beliefs and influence world view…respect indigenous helping practices…awareness of generic aspects of dominant-based counseling and potential clashes with other culture perspectives…exercise institutional intervention skills on behalf of the client…understand sociopolitical dynamics and work to eliminate biases, prejudices, discriminatory, racist and oppressive means…

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MARRCH’s Integrative Decision-Making Models of Ethical Behavior in Counseling

Stage I: Interpreting the situation thru awareness and fact-finding

• Enhance sensitivity and awareness; Determine if dilemma or issue is involved; Determine major stakeholders/ethical claims in situation; Engage in fact-finding process

Stage II: Formulating an ethical decision

• Review problem/dilemma; Determine what ethical codes, laws, ethical principles, and institutional policies and procedures exist that apply to problem/dilemma; Generate possible and probable courses of action; Consider potential positive and negative consequences for each course of action; Consult with supervisors and other knowledgeable professionals; Select the best ethical course of action.

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MARRCH’s Integrative Decision-Making Models of Ethical Behavior in Counseling

Stage III: Selecting an action of weighing competing, non-moral values

• Engage in reflective recognition and analysis of personal competing values; Consider contextual influences on values selection at the collegial team, institutional, and societal levels

Stage IV: Planning and executing the selected course of action

• Figure out a reasonable sequence of actions to be taken; Anticipate and work out personal and contextual barriers to effective execution of the action plan, and effective counter measures for them; Carry out, document, and evaluate the course of action as planned

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